title: Challenges and lessons learned from implementing a risk-based approach to school advice and closure during the containment phase of the 2009 influenza pandemic in the West Midlands, England.
abstract: OBJECTIVE
  School closure as a social distancing measure was used in some countries during the initial phases of the influenza A(H1N1)pdm09 pandemic. The objective of this paper is to describe the use of a risk-based approach to public health interventions for schools during the 'containment phase' of the pandemic and to describe lessons learnt.
  
  
  METHODS
  The development of a framework for risk assessment and decision-making to determine school closures in the West Midlands, England, during the 'containment phase' of influenza A(H1N1)pdm09 pandemic is described.
  
  
  RESULTS
  Using the framework developed during the 'containment phase', assessments were conducted for 344 educational institutions who reported confirmed cases or 'particularly high absenteeism'. Of these, 209 (60%) had confirmed cases and 65 were closed, mainly for public health or operational reasons. Schools were closed on an individual basis, during the most intense period of the pandemic and for an average period of six days (maximum 11 days). The risk-based approach evolved as experience and knowledge of influenza A(H1N1)pdm09 pandemic virus increased, however some decisions were difficult to communicate to parents, schools and stakeholders particularly when the number of schools affected escalated and the pandemic response phases changed.
  
  
  CONCLUSIONS
  The management of school closures is an 'uncertain art'. Numerous challenges and lessons were identified in attempting, during the containment phase of the influenza A(H1N1)pdm09 pandemic, to ensure consistency and transparency in an increasingly complex process. The overall approach described could be further developed to improve decision-making for infectious diseases in schools.
authors.affiliation: Health Protection Agency West Midlands, Birmingham, UK.
authors.forename: A
authors.initials: A
authors.lastname: Awofisayo
authors.forename: S
authors.initials: S
authors.lastname: Ibbotson
authors.forename: G E
authors.initials: GE
authors.lastname: Smith
authors.forename: K
authors.initials: K
authors.lastname: Janmohamed
authors.forename: H
authors.initials: H
authors.lastname: Mohamed
authors.forename: B
authors.initials: B
authors.lastname: Olowokure
mesh_terms: D003264:Containment of Biohazards / Q000379:methods*; D004739:England / Q000453:epidemiology; D006801:Humans; D053118:Influenza A Virus, H1N1 Subtype; D007251:Influenza, Human / Q000517:prevention & control*; D058873:Pandemics / Q000517:prevention & control*; D018570:Risk Assessment; D012574:Schools / Q000458:organization & administration*
keywords: Children; H1N1; Influenza; Pandemic; Risk-based; School closure